Abstract
Background and aim
The outbreak of coronavirus (COVID-19) has made a global public health disaster. Little information is known about how to combat this infection. Therefore, preventive health measures that can reduce the severity and progression of this disease are needed. Some dietary supplements and herbal products have antiviral and anti-inflammatory effects. Thus, it may be used to enhance immunity and reduce the risk of COVID-19 infection. In this study, we reviewed selected supplements that may play a key role in the prevention and management of COVID-19 (e.g. vitamin D, vitamin C, and zinc), and that was to determine the level of knowledge and attitudes toward them by the adult population in Jordan.
Methodology
This is a cross-sectional study design, in which an online questionnaire was conducted and distributed on different social media websites. People who are above 18 years old were included in this study. Demographic, Attitudes, and knowledge data were collected and then analyzed using the Statistical Package for Social Sciences (SPSS 23).
Results
In this study, (62.8%) of participants became more concerned with their health during the COVID-19 pandemic, and (49.2%) of them used dietary and herbal supplements to protect themselves from the coronavirus. In addition, (18.5%) of participants reported that they had used these supplements for a while and then stopped.
Conclusion
The findings of our study provided evidence that the general population in Jordan has a reasonable level of knowledge and acceptance of dietary and herbal supplements used during the COVID-19 pandemic.
Keywords: Herbal supplements, Dietary supplements, COVID-19, Attitudes
Introduction
In December 2019, specifically in Wuhan, China, a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged and subsequently spread all over the world causing a pneumonia outbreak [1]. Subsequently, the World Health Organization (WHO) called it Coronavirus Disease 2019 (COVID-19) [2], and on March 11, 2020, WHO classified COVID-19 as a pandemic [3]. COVID-19 as a Pandemic [3]. Patients with COVID-19 showed a variety of signs and symptoms including fever, cough, myalgia or fatigue, headache, sputum production, shortness of breath, diarrhea [[4], [5], [6]], and alterations in smell or taste [7]. In severe cases, complications were developed, such as hypoxemia, pneumonia, acute respiratory distress syndrome, and sepsis [5,8]. On the other hand, some COVID-19-infected individuals were asymptomatic [9].
Jordan was among the countries that were affected by the COVID-19 pandemic, as Jordan had gone through four waves of coronavirus spread. [10] According to the last published data by the Ministry of Health, 1,731,549 confirmed cases of COVID-19 were reported. [11]. Further, Jordan started its COVID-19 vaccination program in January 2021. The Ministry of Health asked all residents of Jordan, including refugees, to register for free vaccination [12]. Four vaccines were approved in Jordan: Pfizer-BioNTech, Oxford-AstraZeneca, Sinopharm (Beijing) and Sputnik V (Gamaleya). [13].
Since the COVID-19 pandemic started, people all around the world have increased their knowledge and awareness of the different interventions that would highly boost their immune systems. Dietary supplements are some of the known ways that can support the immune system, and therefore they could reduce the risk of COVID-19 infection for healthy individuals [14]. The term “Dietary supplement” is a product of dietary ingredients such as vitamins, minerals, herbs, botanicals, and probiotics; which can be taken orally in many forms including pills, capsules, and drinks [15,16].
The use of dietary and herbal products to decrease the risk of COVID-19 infection was needed to boost immunity in light of unavailable authorized treatment for COVID-19 at that time [17]. Vitamin C, for example, has demonstrated a significant role in boosting immunity as it supports several cellular functions of both adaptive and innate immune systems. Also, it was found that the risk of pneumonia decreased when oral vitamin C supplements has been taken [18,19]. Vitamin C is likely to be needed in higher amounts during infections (2–3g/day), that's because of its higher consumption during states of physiological stress like infections [18]. In addition to vitamin C, zinc and vitamin D have the strongest evidence for supporting and boosting immunity [14].
Vitamins and minerals are easily accessible in pharmacies; therefore, it's thought that during the COVID-19 pandemic, individuals increased their consumption of dietary supplements [20]. Furthermore, increasing knowledge and improvement of attitudes toward these supplements may help in limiting the spread of this viral infection. This study aimed to evaluate the level of knowledge, attitudes, and patterns of adults in Jordan towards dietary supplements and herbal products during the COVID-19 pandemic, and to determine the alteration in herbal and dietary supplement intake due to COVID-19.
Methodology
Study design and population
This cross-sectional survey was conducted from December 5, 2020, to February 25, 2021. The target population in this study was adults aged 18 years and above in Jordan. The survey instrument was distributed online on social media including WhatsApp, Facebook, and Twitter. Participants' consent was implied as participants agreed to take part and fill out the survey online.
Survey instrument
The survey instrument was modified based on extensive literature reviews on the COVID-19 pandemic, including its transmission and preventive measures and the use of traditional medicine in a nearby country (Saudi Arabia) [21]. Three researchers reviewed the questionnaire tool to evaluate the appropriateness, relevancy, clarity, and adequacy of the questions. A draft of the questionnaire was reviewed again and pretested by the researchers, and it was estimated to require about 5 minutes to complete. A pilot version was generated based on their feedback, and pilot testing of the questionnaire was then conducted by three physicians and two clinical pharmacists to assess its content and face validity. Feedback and comments by the pilot group were considered among the research team to improve clarity and understanding of the questionnaire items before finalizing the questionnaire for general administration. These comments included shortening some questions, clarifying some wording, and giving examples for some items. In addition, this process was guided by reading about how to conduct survey research [22]. The survey was translated to the Arabic language by two independent researchers using forward and backward translation processes between Arabic and English. Persons who were of Jordanian nationality, were aged 18 years or more, understood the content of the survey, and agreed to participate in the study, were instructed to complete the questionnaire byia clicking the link. The study was approved by the Institutional Review Board (IRB) of Jordan University of Science and Technology (JUST) before the questionnaire was distributed (IRB #:4/137/2020). Participants were invited to participate in the online survey after a brief overview about the purpose of the study, the nature of the questions, and a statement assuring the confidentiality of participants' information. Participants were asked if they want to voluntarily participate. The final questionnaire was composed of three parts as follows.
Part 1. Demographic and general information
Demographic variables included age, gender, residence, education, employment status, health insurance status, marital state, chronic disease history, chronic medication user, physical activity level, and smoking status.
Part 2. Knowledge about dietary supplements and herbal products as protective measures during COVID-19
The part of the questionnaire had 31 questions. The participants responded to questions regarding dietary supplement use, safety, and source of information. Questions were answered on a yes/no basis with an additional “I don't know” option.
Part 3. Attitudes and practices toward dietary supplements and herbal products during COVID-19
This part of the questionnaire had nine questions. Participants responded to questions about their awareness of dietary supplements and herbal products, their beliefs in usefulness, and others in reducing or preventing COVID-19. Responses to the attitudes questions were framed as a 5-point Likert Scale (strongly agree, agree, neutral, disagree, and strongly disagree). A score for positive attitude was calculated for each participant using items that indicate positive attitudes toward both herbal supplements and vitamins during the COVID-19 pandemic. These items include the first, second, third, fifth, eighth, and ninth as indicated in Table 4 . The number of included items was 6, and they were scored on a 5-point Likert Scale with a response of 1 indicating that the respondent strongly disagrees to a response of 5 indicating the respondent strongly agrees with the corresponding attitude. The score is calculated by summing the responses for each participant with a maximum of 30 points score.
Table 4.
Attitudes and practices toward dietary and herbal products during COVID-19.
| Statement | Strongly disagree N (%) | Disagree N (%) | Neutral N (%) | Agree N (%) | Strongly agree N (%) |
|---|---|---|---|---|---|
| I consider taking both dietary and herbal supplements at the same time will be more efficient so they can help in preventing COVID-19. | 13 (2.5%) | 39 (7.6%) | 135 (26.3%) | 247 (48.1%) | 80 (15.6%) |
| Herbal and dietary supplements can increase immunity. | 6 (1.2%) | 7 (1.4%) | 58 (11.3%) | 308 (59.9) | 135 (26.3%) |
| I feel safer when taking some dietary and herbal supplements during the COVID-19 pandemic. | 4 (0.8%) | 46 (8.9%) | 137 (26.7%) | 252 (49%) | 75 (14.6%) |
| I don't think taking herbal and/or dietary supplements will help in preventing COVID-19. | 47 (9.1%) | 213 (41.4%) | 153 (29.8%) | 84 (16.3%) | 17 (3.3%) |
| Herbal and dietary supplements are easily accessible. | 5 (1%) | 28 (5.4%) | 72 (14%) | 302 (58.8%) | 107 (20.8%) |
| Vitamins like (C, D, and Zinc) may help prevent COVID-19, but herbal supplements are not. | 16 (3.1%) | 158 (30.7%) | 178 (34.6%) | 122 (23.7%) | 40 (7.8%) |
| Herbal Products like (Aniseed, garlic, and fish oil, i.e.) may have a role in preventing COVID-19, but dietary supplements are not. | 22 (4.3%) | 211 (41.1%) | 181 (35.2%) | 77 (15%) | 23 (4.5%) |
| Dietary and herbal supplements are safe as they don't have any side effects. | 19 (3.7%) | 108 (21%) | 138 (26.8%) | 194 (37.7%) | 55 (10.7%) |
| Dietary and herbal supplements can treat a person infected with COVID-19. | 20 (3.9%) | 64 (12.5%) | 154 (30%) | 225 (43.8%) | 51 (9.9%) |
Statistical analysis
Descriptive statistics such as percentages and arithmetic means with standard deviations were calculated to describe participants' demographics, participant's knowledge, and attitudes toward dietary and herbal supplements during the COVID-19 pandemic. A multivariable linear logistic regression model was conducted to assess predictors of high agreement levels with acceptance attitudes toward dietary and herbal supplements. Sample size calculation was based on the following formula: and estimated to be 510. All data analyses were conducted using SPSS v23. Statistical significance was set at a 2-sided P<0.05.
Results
Baseline sociodemographic characteristics and health status of participants
A total of 514 participants met the inclusion criteria and thus responded to the study survey. Table 1 demonstrates the demographic characteristics of the study participants. In general, most participants were females (68.7%), located in the Northern region (58.2%), with a bachelor's degree (70.6%), and medically insured (73.2%). Most participants did not have a history of chronic diseases (84.4%) and reported a very good health status (45.5%). Other demographics and health information of the study sample are mentioned in detail in Table 1.
Table 1.
Baseline sociodemographic characteristics of participants (n=514).
| Characteristics | Frequency (n) | Percent (%) |
|---|---|---|
| Age (mean±SD) | 33±6 | |
| Gender | ||
| Male | 161 | 31.1 |
| Female | 353 | 68.7 |
| Place of residence (region) | ||
| North | 299 | 58.2 |
| Middle | 198 | 38.5 |
| South | 17 | 3.3 |
| Education | ||
| Bachelor's degree | 363 | 70.6 |
| High School | 8 | 1.5 |
| High school Graduate | 28 | 5.4 |
| Diploma/College | 51 | 9.9 |
| Masters or doctorate | 64 | 12.5 |
| Employment status | ||
| Student | 139 | 27 |
| Unemployed | 126 | 24.5 |
| Retired | 28 | 5.4 |
| Employee | 221 | 43 |
| Working in the health care sector | ||
| No | 399 | 77.6 |
| Yes | 115 | 22.4 |
| Health Insurance Status | ||
| Uninsured | 138 | 26.8 |
| Insured | 376 | 73.2 |
| Marital Status | ||
| Widowed/divorced | 16 | 3.1 |
| Single | 293 | 57 |
| Married | 205 | 39.9 |
| Chronic Disease History | ||
| No | 434 | 84.4 |
| Yes | 80 | 15.6 |
| Chronic disease(s) | ||
| Hypertension | 20 | 3.9 |
| Diabetes | 15 | 2.9 |
| Respiratory Chronic Diseases | 14 | 2.9 |
| Others | 125 | 24.3 |
| Chronic medication use | ||
| No | 443 | 86.2 |
| Yes | 71 | 13.8 |
| Overall health status | ||
| Good | 107 | 20.8 |
| Very Good | 234 | 45.5 |
| Poor | 5 | 1 |
| Fair | 40 | 7.8 |
| Excellent | 128 | 24.9 |
| Smoking status | ||
| Nonsmokers | 409 | 79.6 |
| Smokers | 105 | 20.4 |
| The daily smoking rate for smokers | ||
| Less than 6 cigarettes per day | 31 | 6 |
| From 7 to 13 cigarettes per day | 22 | 4.3 |
| From 13 to 24 cigarettes per day | 40 | 7.8 |
| More than 24 cigarettes per day | 13 | 2.5 |
| Physical activity Level | ||
| Sedentary (no exercise) | 190 | 37 |
| Light Active (1–3 times per week) | 189 | 36.8 |
| Moderate Active (3–5 per week) | 109 | 21.2 |
| Very Active (6–7 per week) | 20 | 3.9 |
| Heavy Active (more than 7 per week) | 6 | 1.2 |
Knowledge about dietary supplements and herbal products as protective measures during COVID-19
Before the pandemic, vitamin C was the most used vitamin by the study participants (33.5%), followed by honey (29.4%), and vitamin D (28.6%). During the pandemic, most of the participants were using vitamin C (59.5%), Zinc (30.7%), and vitamin D (29.8%) to protect them from COVID-19 infection. Other supplements that were used by the participants in the current study before and during the pandemic are reported in Table 2.
Table 2.
Dietary supplements and herbal products use before and during the COVID-19 pandemic.
| Before the pandemic n (%) | During the pandemic n (%) | |
|---|---|---|
| Vitamin C | 172 (33.5%) | 308(59.9%) |
| Vitamin D | 147 (28.6%) | 153 (29.8%) |
| Zinc | 75 (14.6%) | 158(30.7%) |
| Probiotics | 6 (1.2%) | 6 (1.2%) |
| Turmeric | 72 (14%) | 60 (11.7%) |
| Aniseed | 133 (25.9%) | 142(27.6%) |
| Sage | 135 (26.3%) | 102 (19.8%) |
| Garlic | 92 (17.9%) | 87 (16.9%) |
| Ginger | 114 (22.2%) | 107 (20.8%) |
| Fish oil | 37 (7.2%) | 29 (5.6%) |
| Multivitamins | 76 (14.8%) | 64 (12.5%) |
| Honey | 151 (29.4%) | 146 (28.4%) |
| Iron | 70 (13.6%) | 53 (10.3%) |
| Cumin | 44 (8.6%) | 51 (9.9%) |
| Raw onion | 76 (14.8%) | 77 (15%) |
| Vinegar | 33 (6.4%) | 23 (4.5%) |
| Salted Water | 14 (2.7%) | 20(3.9%) |
| Folic Acid | 15 (2.9%) | 16 (3.1%) |
| Magnesium | 15 (2.9%) | 18 (3.5%) |
| B12 | 97 (18.9%) | 56 (10.9%) |
| B-Complex | 37 (7.2%) | 24 (4.7%) |
| Others | 108 (21%) | 92 (17.9%) |
A total of 79% of participants reported that dietary supplements and herbal products could not substitute food to provide all nutritional benefits. A bit more than half of the participants (57.6%) responded that social distancing is more effective than consuming some dietary and herbal supplements to prevent COVID-19 infection. In terms of participants' beliefs about using dietary supplements and herbal supplements as a protective measure, 76.5% of the participants believe that taking vitamin C helps in reducing the chances of developing COVID-19, followed by zinc (66.9%). Table 3 shows further details about beliefs regarding the use of dietary supplements and herbal products as a protective measure. Regarding the source of advice related to the use of dietary and herbal supplements, most participants sought advice from their friends/relatives, social media/internet, physician, or pharmacist, ((28.8%), (25.3%), (18.3%), (16.5%)), respectively.
Table 3.
Beliefs regarding the use of dietary supplements and herbal products as a protective measure.
| Questions | No N (%) | I don't know N (%) | Yes N (%) |
|---|---|---|---|
| Dietary and herbal supplements can substitute food because they provide all nutritional benefits? | 406 (79%) | 77 (15%) | 31 (6%) |
| Do you think vitamin C supplement helps increase immunity and reduce the chance of developing COVID- 19? | 54 (10.5%) | 67 (13%) | 393 (76.5%) |
| Do you think vitamin D Helps increase immunity and reduce the chance of developing COVID-19? | 89 (17.3%) | 133 (25.9%) | 292 (56.8%) |
| Do you think Zinc can improve immunity and reduce the chance of developing COVID-19? | 55 (10.7%) | 115 (22.4%) | 344 (66.9%) |
| Do you think Probiotics can improve immunity and reduce the chance of developing COVID-19? | 95 (18.5%) | 330 (64.2%) | 89 (17.3%) |
| Do you think Cumin can improve immunity and reduce the chance of developing COVID-19? | 91 (17.7%) | 267 (51.9%) | 156 (30.4%) |
| Do you think Aniseed can improve immunity and reduce the chance of developing COVID-19? | 112 (21.8%) | 206 (40.1%) | 196 (38.1%) |
| Do you think Sage can improve immunity and reduce the chance of developing COVID-19? | 143 (27.8%) | 230 (44.7%) | 141 (27.4%) |
| Do you think Garlic can improve immunity and reduce the chance of developing COVID-19? | 65 (12.6%) | 125 (24.3%) | 324 (63%) |
| Do you think Ginger can improve immunity and reduce the chance of developing COVID-19? | 78 (15.2%) | 160 (31.1%) | 276 (53.7%) |
| Do you think Fish oil can improve immunity and reduce the chance of developing COVID-19? | 89 (17.3%) | 222 (43.2%) | 203 (39.5%) |
| Do you think Honey can improve immunity and reduce the chance of developing COVID-19? | 63 (12.3%) | 123 (23.9%) | 328 (63.8%) |
| Do you think Iron can improve immunity and reduce the chance of developing COVID-19? | 94 (18.3%) | 198 (38.5%) | 222 (43.2%) |
| Do you think consuming Raw onion can improve immunity and reduce the chance of developing COVID-19? | 86 (16.7%) | 138 (26.8%) | 290 (56.4%) |
| Do you think consuming Vinegar can improve your immunity and then reduce the chance of developing COVID-19? | 140 (27.2%) | 268 (52.1%) | 106 (20.6%) |
| Do you think Salted water can improve immunity and reduce the chance of developing COVID-19? | 145 (28.2%) | 220 (42.8%) | 149 (29%) |
| Do you think Folic Acid can improve immunity and reduce the chance of developing COVID-19? | 107 (20.8%) | 300 (58.4%) | 107 (20.8%) |
| Do you think Magnesium can improve immunity and reduce the chance of developing COVID-19? | 101 (19.6%) | 292 (56.8%) | 121 (23.5%) |
| Do you think Vitamin B-12 can improve immunity and reduce the chance of developing COVID-19? | 102 (19.8%) | 226 (44%) | 186 (36.2%) |
| Do you think B-complex can improve immunity and reduce the chance of developing COVID-19? | 81 (15.8%) | 246 (47.9%) | 187 (36.4%) |
| Do you think that consuming some dietary and herbal supplements is more effective in preventing COVID-19 compared to social distancing | 296 (57.6%) | 103 (20%) | 115 (22.4%) |
| Do you think that some dietary and herbal supplements may have an impact on reducing the incidence of COVID-19? | 96 (18.7%) | 109 (21.2%) | 309 (60.1%) |
| Do you think that some herbal and dietary supplements can be effective in treating COVID-19? |
107 (20.8%) |
124 (24.1%) |
283 (55.1%) |
| No (%) |
Not much (%) |
Yes (%) |
|
| Does this pandemic increase your knowledge about nutritional supplements and herbal products and their role in enhancing your health? | 70 (13.6%) | 141 (27.4%) | 303 (58.9%) |
Attitudes and practices toward dietary supplements and herbal products during COVID-19
The average calculated score for positive attitude was 22.1 with a standard deviation of 3.4 and ranging from 6 to 30 and responses are depicted in Table 4. More than half of the participants (58.1%) agreed that taking both dietary supplements and herbal products at the same time will be more efficient in preventing COVID-19 infection, 59.9% agreed that dietary and herbal supplements could increase immunity, and 49% agreed that they feel safer when taking some of the dietary and herbal supplements. Finally, 43.8% of the participants agreed that dietary and herbal products could treat a person infected with COVID-19. The factors that prevent people from using dietary and herbal products during the corona were that they cannot take them regularly (32.4%), followed by inappropriate prices (13.6%) as shown in Table 5.
Table 5.
Factors that prevent participants from using supplements during the COVID-19 pandemic.
| What are the factors that prevent you from using nutritional supplements and herbal products during the COVID-19 pandemic? | n | % |
|---|---|---|
| Their prices are inappropriate | 70 | 13.6 |
| Difficulty accessing it | 15 | 2.9 |
| I cannot take it regularly | 166 | 32.3 |
| I do not think it has a role in treating the Coronavirus | 45 | 8.8 |
| Not covered by insurance | 46 | 8.9 |
| No reasons | 172 | 33.5 |
Results from linear regression analysis showed that age, gender, employment, working in health sectors, marital status, exercise, and education were significant predictors for positive attitudes scores. Being males compared to females was significantly associated with decreasing the attitude score by 1.241 (P value= 0.001). Compared to students, employed participants had significantly higher attitude scores by 0.9; (P-value = 0.034). Participants who were working in health sectors had significantly lower scores (coefficient = -.79, P-value = 0.034) compared to those not working in health fields. Married participants have an increased attitude score by (1.02) compared to single participants (P-value = 0.022). In addition, participants who usually exercise 1–3 times/week and 3–5/week had significantly higher attitude scores (0.7 and 1.06, respectively) compared to those who were not exercising. Finally, participants with a bachelor's degree education had significantly decreased attitude scores by 1.009, compared to those with less than a bachelor's degree. Detailed results are shown in Table 6 .
Table 6.
Predictors of high agreement levels with positive attitudes among dietary and herbal supplements during COVID-19.
| Attitude score | Coef. | P>|t| | 95% CI |
|---|---|---|---|
| Age | -0.04779 | 0.053 | (-0.0960–0.0005) |
| Gender (reference females) | -1.24321 | 0.001 | (-1.9733 - -0.5131) |
| Employment Status | |||
| Students | Reference | ||
| Unemployed | 0.402535 | 0.388 | (-0.5119 – 1.3170) |
| Employed | 0.918971 | 0.034 | (0.0674–1.7704) |
| Retired | 1.089345 | 0.247 | (-0.7560 – 2.9347) |
| Health Field | -0.79256 | 0.034 | (-1.5230 - -0.06206) |
| Insurance | -0.36245 | 0.296 | (-1.0427 – 0.3177) |
| Marital Status | |||
| Single | Reference | ||
| Married | 1.02294 | 0.022 | (0.1483–1.8975) |
| Divorced/Widowed | 1.779581 | 0.068 | (-0.1307 – 3.6898) |
| Having Chronic Disease | 0.225264 | 0.616 | (-0.6578 – 1.1083) |
| Exercise Frequency | |||
| None | Reference | ||
| 1-3 Times/Week | 0.719334 | 0.039 | (0.0352–1.4034) |
| 3-5 Times/Week | 1.062725 | 0.01 | (0.2542–1.8712) |
| 6 or more Times/Week | 0.613681 | 0.385 | (-0.7734 – 2.0008) |
| Smoking | 0.33673 | 0.413 | (-0.4707 – 1.1442) |
| Education | |||
| Less than Bachelor | Reference | ||
| Bachelor | -1.0097 | 0.019 | (-1.8498 - -0.1696) |
| Graduate studies | -0.67674 | 0.236 | (-1.7965 – 0.4430) |
| Health Status | |||
| Neutral or Good | Reference | ||
| Very Good | 0.428175 | 0.235 | (-0.2800 – 1.1363) |
| Excellent | 0.0842 | 0.843 | (-0.7485 – 0.9169) |
Discussion
This cross-sectional study assessed basic knowledge, attitudes, and practices toward dietary and herbal supplements among adult residents (over 18 years) in Jordan. Most participants were females (68.7%), and more than half of the participants (58.2%) were living in the northern region of Jordan, while 3.3% were living in the southern region of Jordan, and the rest (38.5%) were living in the middle region of Jordan. This could be because the survey did not reach adequately the people living in the south of Jordan. Regarding employment status, employees, students, and unemployed were (43%, 27%, and 24.5%), respectively, while (5.4%) of participants were retired; this is probably because the survey was distributed via various social media platforms, and retired individuals are advanced in age, and not familiar with the use of these platforms. Moreover, the majority of participants reported very good and excellent health status, (45.5% and 24.9%), respectively. This comes in consistent with (84.4%) of participants reporting no chronic disease history and 86.2% reported no chronic medication use. However, the overall health status was self-reported, which means the participants' evaluation of their health status may not be accurate.
This study assessed the participants' knowledge about dietary and herbal supplements among the general population aged 18 years or above in Jordan. The level of knowledge was assessed between the users and non-users of herbal and dietary supplements. In our study, (62.8%) of the participants became more concerned about their health during the COVID-19 pandemic, (and 49.2%) of them used dietary and herbal supplements to protect themselves from coronavirus. Compared to an Alyami et al. study, which is a cross-sectional study in Saudi Arabia, around (22.1%) of the participants reported consuming different dietary supplements and herbal products to decrease the risk of COVID-19 infection [15]. In another study, (34%) of participants reported consuming dietary supplements during the pandemic (specifically during quarantine) [23]. Furthermore, In our study, vitamin C was found to be the most dietary supplement used as a preventive measure before and during the COVID-19 pandemic. This comes consistent with Alyami et al. study, in which vitamin C was the most dietary supplement consumed (94.4%) in Saudi Arabia before and during the COVID-19 pandemic [19]. Moreover, before the pandemic, the percentage of participants who were taking vitamin C and zinc were (33.5%) and (14.6%), respectively. However, during the pandemic, the use of vitamin C and zinc significantly increased, with which (59.9%) and (30.7%) of participants reported taking vitamin C during the pandemic, respectively (P < 0.0001). In a cross-sectional study held in Lebanon, the weekly or daily estimated taken amount of vitamin C increased significantly during the pandemic period (42.1%) as compared to before the pandemic (35.3%) (P < 0.001) [24]. Zinc use as well has increased significantly among Lebanese people, in which the weekly or daily estimated taken amount of zinc has increased significantly from (18.8%) before the pandemic to (29.3%) during the pandemic period (P < 0.001) [20]. In addition, our results reported that (28.6%) of participants were using vitamin D before the COVID-19 pandemic. However, during the pandemic, vitamin D use among participants increased significantly to (29.8%) (P < 0.0001). According to a Lebanese study, the weekly or daily estimated taken amount of vitamin D has increased significantly to (41%) during the pandemic period as compared to (35.5%) before the pandemic (P < 0.001) [24]. A large number of participants reported using herbal products to lower the risk of COVID-19 infection. About (28.4%) of participants were using honey during the pandemic, (27.6%) aniseed, (20.8%) ginger, (19.8%) sage, (and 16.9%) garlic. This finding is consistent with a Bengali study, where 57.6% of the study's participants were taking herbal foods/products to mitigate the chance of COVID-19 infection [17].
Regarding beliefs on using dietary and herbal supplements as a protective measure, 76.5% of the participants believe that taking vitamin C helps in reducing the chances of developing COVID-19. This is evident by its vital properties as an antioxidant, anti-inflammatory, and antiviral effect, as well as its role in supporting both adaptive and innate immune systems [18]. Regarding zinc, (66.9%) of participants believe that zinc has a pivotal role as a preventive measure against COVID-19. Zinc has a significant role in optimizing immune response and inhibiting viral replication, therefore protecting against COVID-19 [25,26]. Furthermore, (56.8%) of the participants thought that vitamin D may play a role in human immunity and decrease the chance of getting infected with COVID-19. Vitamin D decreases the risk of infections through increasing concentrations of anti-inflammatory cytokines, as well as decreasing concentrations of pro-inflammatory cytokines, thus, it has a significant role in preventing COVID-19 infection [27,28]. Moreover, low concentrations of vitamin D have been associated with acute respiratory distress syndrome [26]. Moreover, our participants were familiar with herbal supplements. They thought that garlic, ginger, honey, and raw onion are the products that might play a role in increasing immunity and decreasing the chance of developing COVID-19 in a percentage of (63%, 53.7%, 63.8%, 56.4%), respectively. Herbal supplements are found to have antiviral properties and thus play an important role against several viruses, also, support the immune system and control both types of immunity (adaptive and innate) [29]. In another regional study, (34.4%) of participants think that garlic boosts the functionality of the immune system, thus reducing the risk of developing COVID-19 [19].
Our study assessed the population's general knowledge regarding the preventive measures for the COVID-19 pandemic, such as social distancing. A bit more than half of the participants (57.6%) believe that social distancing is more effective than dietary and herbal supplement consumption in preventing COVID-19. This is consistent with a study held in Saudi Arabia, where Participants' knowledge about social distancing as a COVID-19 preventive measure was moderate [19]. Our study indicated that (79%) of participants reported that dietary and herbal supplements could not substitute for food to provide all the nutritional benefits. On contrary, there was a 4.3% significant increase in the percentage of those who believe that dietary supplements are capable of replacing food in a Lebanese study [24]. In addition, our study participants thought that consuming some dietary and herbal supplements could reduce the incidence of COVID-19 infection and could be effective tools in treating COVID-19 percentage of (60.1%, 55.1%), respectively. According to European Food Safety Authority (EFSA), there are many vitamins and minerals (vitamin D, A, C, Folate, B6, B12, zinc, iron, copper, and selenium) that have the potential to prevent and treat COVID-19 symptoms [24]. When participants of this study were asked if this pandemic increased their knowledge concerning nutritional supplements and herbal products, and their role in enhancing human health, (58.9%) of participants answered yes, indicating that people were interested in enriching their knowledge regarding products that would decrease their risk of developing an infection in the light of such medical emergency and lack of specified treatment for COVID-19. Furthermore, Participants were asked about the source of advice regarding dietary and herbal supplements, most answers were friends/relatives (28.8%), social media/internet (25.3%), physicians (18.3%), or pharmacists (16.5%). Compared to a cross-sectional study conducted in Bangladesh, the sources of advice related to dietary supplements were friends/family/relatives (40.1%), Physicians (25%), TV/newspaper (22.8%), Facebook/Twitter (20.8%), pharmacist (18.3%), or internet (16.3%) [13]. In another study conducted in Lebanon, the medical prescription was the main source of advice during the COVID-19 pandemic, where (58.9%) of participants used dietary supplements based on medical prescription. Moreover, (17.6%) of participants used dietary supplements depending on the dietitian's advice [24].
This study evaluated participants' attitudes toward dietary and herbal products during COVID-19, in which nearly half of our participants (48.1%) agreed that using both dietary and herbal supplements at the same time will be more efficient in preventing COVID-19 ((15.6%) strongly agree). In addition, most of the participants (59.9%) agreed that herbal and dietary supplements could increase immunity. This is consistent with another study conducted in Lebanon, where (73.7%) of participants reckon that dietary and herbal supplements are of benefit to their immunity system during COVID-19 [20]. The majority of participants agreed that they feel safer when they take some dietary and herbal supplements during the pandemic [(49%) agree, (14.6%) strongly agree)]. This indicates that most people in Jordan believe in the role of dietary and herbal supplements in health, specifically regarding immunity. Half of the participants also think that taking dietary and herbal supplements will help in preventing COVID-19, (41.4%) disagree and (9.1%) strongly disagree that taking these supplements will not help in preventing COVID-19. More than half of the participants agreed that dietary and herbal supplements are easily accessible, where individuals can easily reach pharmacies and buy various supplements without the need for consulting a physician. Moreover, nearly a third of participants agreed that vitamins like (C, D, and zinc) might have a role in preventing COVID-19 infection, while herbal products do not have that role ((23.7%) agree, (7.8%) strongly agree). However, around a third of participants were not certain if vitamins protect against COVID-19 and herbal supplements are not ((34.6%) neutral). On contrary, nearly a fifth of participants agreed that herbal supplements like (aniseed, garlic, and fish oil) might have a role in preventing COVID-19 infection, and dietary supplements do not (15%) agree, (4.5%) strongly agree). However, about a third of participants were not confident that herbal supplements decrease the risk of COVID-19 infection and vitamins do not ((35.2%) neutral). Furthermore, nearly half of the participants agreed that dietary and herbal supplements are safe, and don't have any side effects (37.7%) agree, (10.7%) strongly agree). On the other hand, around a quarter of participants disagreed that Dietary and herbal supplements are safe, and do not cause adverse effects ((21%) disagree, (3.7%) strongly disagree).
The biggest obstacles that faced the participants, and prevented them from using dietary and herbal supplements where they cannot take them regularly (32.3%) which is an adherence problem, followed by their prices, as (13.6%) of participants think that they are inappropriate. However, (33.5%) of participants responded with no reason, it's probably because of the lack of data on the appropriate treatment for COVID-19. Compared to a Lebanese study, the high price of dietary supplements was reported as a significant factor for avoiding dietary supplements by (20.4%) and (24.8%) of participants before and during the pandemic, respectively [24].
There are some limitations, such as this is a study of cross-sectional design, in which determining the causal relationship is not feasible. Furthermore, there was a limited number of studies that evaluate the knowledge, attitudes, and practices toward dietary and herbal supplements use during the COVID-19 pandemic worldwide, the Arabic speaking countries specifically, which limited the studies that we can compare our findings with. Moreover, our survey was distributed via different social media platforms (online survey), this method of distribution could limit reaching the possible targeted population, which could lead to a selection bias. Besides, the results of our study are self-reported by the participants, which may lead to a non-differential information bias. Also, the study-specific characteristics were divided into multiple groups, and the sample size of each group is relatively small, therefore, we recommend future studies with a larger sample size to get more inclusive results.
Conclusions
The findings of our study provided evidence that the general population in Jordan has a reasonable level of knowledge and accepted attitudes toward dietary and herbal supplements. Also, they are aware of the role of dietary and herbal supplements in enhancing immunity, which in turn may help in protecting against coronavirus. Our study also showed a significant increase in using some supplements during the pandemic compared to before the pandemic.
Financial support
This study did not receive any funds.
Data availability
Data will be shared based on request.
Authors’ contribution
MA, SA, and SH conceived and designed the study. MA, AM, and SH performed data collection. ST, MA, and ST conducted data analysis and data interpretation. All authors had a role in writing and preparing the final version of the manuscript. All authors approved the final version of the manuscript.
Conflicts of interest
There is no conflict of interest.
References
- 1.Zu Z.Y., Jiang M.D., Xu P.P., Chen W., Ni Q.Q., Lu G.M., et al. Coronavirus Disease 2019 (COVID-19): A Perspective from China. Radiology. 2020;296(2):E15–E25. doi: 10.1148/radiol.2020200490. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Sohrabi C., Alsafi Z., O'Neill N., Khan M., Kerwan A., Al-Jabir A., et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) Int J Surg. 2020;76:71–76. doi: 10.1016/j.ijsu.2020.02.034. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Habas K., Nganwuchu C., Shahzad F., Gopalan R., Haque M., Rahman S., et al. Resolution of coronavirus disease 2019 (COVID-19) Expert Rev Anti Infect Ther. 2020;18(12):1201–1211. doi: 10.1080/14787210.2020.1797487. [DOI] [PubMed] [Google Scholar]
- 4.Huang C., Wang Y., Li X., Ren L., Zhao J., Hu Y., et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020;395(10223):497–506. doi: 10.1016/S0140-6736(20)30183-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hribar C.A., Cobbold P.H., Church F.C. Potential Role of Vitamin D in the Elderly to Resist COVID-19 and to Slow Progression of Parkinson's Disease. Brain Sci. 2020;10(5) doi: 10.3390/brainsci10050284. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Zhang J.J., Dong X., Cao Y.Y., Yuan Y.D., Yang Y.B., Yan Y.Q., et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy. 2020;75(7):1730–1741. doi: 10.1111/all.14238. [DOI] [PubMed] [Google Scholar]
- 7.Spinato G., Fabbris C., Polesel J., Cazzador D., Borsetto D., Hopkins C., et al. Alterations in Smell or Taste in Mildly Symptomatic Outpatients With SARS-CoV-2 Infection. JAMA. 2020;323(20):2089–2090. doi: 10.1001/jama.2020.6771. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Guan W.J., Ni Z.Y., Hu Y., Liang W.H., Ou C.Q., He J.X., et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708–1720. doi: 10.1056/NEJMoa2002032. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Torres I., Poujois S., Albert E., Colomina J., Navarro D. Evaluation of a rapid antigen test (Panbio COVID-19 Ag rapid test device) for SARS-CoV-2 detection in asymptomatic close contacts of COVID-19 patients. Clin Microbiol Infect. 2021;27(4):636 e1–e4. doi: 10.1016/j.cmi.2020.12.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Qaqish A., Al-Omari M., Abbas M.M., Ghazo M. Two years of COVID-19 pandemic in Jordan: A focus on epidemiology and vaccination. J Glob Health. 2022 Oct 1;12 doi: 10.7189/jogh.12.03063. PMID: 36181720; PMCID: PMC9526477. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Ministry of Health towotJ. Available: https://corona.moh.gov.jo/en. Accessed.
- 12.Hatmal M.M., Al-Hatamleh M.A.I., Olaimat A.N., Hatmal M., Alhaj-Qasem D.M., Olaimat T.M., et al. Side Effects and Perceptions Following COVID-19 Vaccination in Jordan: A Randomized, Cross-Sectional Study Implementing Machine Learning for Predicting Severity of Side Effects. Vaccines (Basel) 2021;9:556. doi: 10.3390/vaccines9060556. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rababa’h A.M., Abedalqader N.N., Ababneh M. Jordanians’ willingness to receive heterologous prime-boost COVID-19 vaccination and vaccine boosters. Eur Rev Med Pharmacol Sci. 2021;25:7516–7525. doi: 10.26355/eurrev_202112_27452. [PubMed] [Google Scholar] [DOI] [PubMed] [Google Scholar]
- 14.Moscatelli F., Sessa F., Valenzano A., Polito R., Monda V., Cibelli G., et al. COVID-19: Role of Nutrition and Supplementation. Nutrients. 2021;13(3) doi: 10.3390/nu13030976. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ronis M.J.J., Pedersen K.B., Watt J. Adverse Effects of Nutraceuticals and Dietary Supplements. Annu Rev Pharmacol Toxicol. 2018;58:583–601. doi: 10.1146/annurev-pharmtox-010617-052844. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Zhai Q., Yang L., Zhao J., Zhang H., Tian F., Chen W. Protective Effects of Dietary Supplements Containing Probiotics, Micronutrients, and Plant Extracts Against Lead Toxicity in Mice. Front Microbiol. 2018;9:2134. doi: 10.3389/fmicb.2018.02134. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Ahmed I., Hasan M., Akter R., Sarkar B.K., Rahman M., Sarker M.S., et al. Behavioral preventive measures and the use of medicines and herbal products among the public in response to Covid-19 in Bangladesh: A cross-sectional study. PLoS One. 2020;15(12) doi: 10.1371/journal.pone.0243706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Holford P., Carr A.C., Jovic T.H., Ali S.R., Whitaker I.S., Marik P.E., et al. Vitamin C-An Adjunctive Therapy for Respiratory Infection, Sepsis and COVID-19. Nutrients. 2020;12(12) doi: 10.3390/nu12123760. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Alyami H.S., Orabi M.A.A., Aldhabbah F.M., Alturki H.N., Aburas W.I., Alfayez A.I., et al. Knowledge about COVID-19 and beliefs about and use of herbal products during the COVID-19 pandemic: A cross-sectional study in Saudi Arabia. Saudi Pharm J. 2020;28(11):1326–1332. doi: 10.1016/j.jsps.2020.08.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kamarli Altun H., Karacil Ermumcu M.S., Seremet Kurklu N. Evaluation of dietary supplement, functional food and herbal medicine use by dietitians during the COVID-19 pandemic. Public Health Nutr. 2021;24(5):861–869. doi: 10.1017/S1368980020005297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Alyami H.S., Orabi M.A., Aldhabbah F.M., Alturki H.N., Aburas W.I., Alfayez A.I., et al. Knowledge about COVID-19 and beliefs about and use of herbal products during the COVID-19 pandemic: A cross-sectional study in Saudi Arabia. Saudi Pharmaceutical Journal. 2020;28(11):1326–1332. doi: 10.1016/j.jsps.2020.08.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Aldridge A. McGraw-Hill Education; UK): 2001. Surveying the social world: principles and practice in survey research. [Google Scholar]
- 23.Bakhsh M.A., Khawandanah J., Naaman R.K., Alashmali S. The impact of COVID-19 quarantine on dietary habits and physical activity in Saudi Arabia: a cross-sectional study. BMC Public Health. 2021;21(1):1487. doi: 10.1186/s12889-021-11540-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Mohsen H., Yazbeck N., Al-Jawaldeh A., Bou Chahine N., Hamieh H., Mourad Y., et al. Knowledge, Attitudes, and Practices Related to Dietary Supplementation, before and during the COVID-19 Pandemic: Findings from a Cross-Sectional Survey in the Lebanese Population. Int J Environ Res Public Health. 2021;18(16) doi: 10.3390/ijerph18168856. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Galmes S., Serra F., Palou A. Current State of Evidence: Influence of Nutritional and Nutrigenetic Factors on Immunity in the COVID-19 Pandemic Framework. Nutrients. 2020;12(9) doi: 10.3390/nu12092738. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Abdulateef D.S., Rahman H.S., Salih J.M., Osman S.M., Mahmood T.A., Omer S.H.S., et al. COVID-19 severity in relation to sociodemographics and vitamin D use. Open Med (Wars) 2021;16(1):591–609. doi: 10.1515/med-2021-0273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Grant W.B., Lahore H., McDonnell S.L., Baggerly C.A., French C.B., Aliano J.L., et al. Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths. Nutrients. 2020;12(4):988. doi: 10.3390/nu12040988. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Akbarzadeh M., Barati-Boldaji R., Mohsenpour M.A., Ferns G.A., Jalali M., Mosallanezhad Z., et al. Did Iranians change their eating behavior following COVID-19 outbreak? J Res Med Sci. 2021;26:116. doi: 10.4103/jrms.JRMS_1234_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Aldwihi L.A., Khan S.I., Alamri F.F., AlRuthia Y., Alqahtani F., Fantoukh O.I., et al. Patients' Behavior Regarding Dietary or Herbal Supplements before and during COVID-19 in Saudi Arabia. Int J Environ Res Public Health. 2021;18(10) doi: 10.3390/ijerph18105086. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data will be shared based on request.